Provider Demographics
NPI:1376142976
Name:KIM, ALEX (MSN, RN, FNP-C)
Entity Type:Individual
Prefix:
First Name:ALEX
Middle Name:
Last Name:KIM
Suffix:
Gender:M
Credentials:MSN, RN, FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15027 CALLE LA PALOMA
Mailing Address - Street 2:
Mailing Address - City:CHINO HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:91709-5011
Mailing Address - Country:US
Mailing Address - Phone:909-973-3178
Mailing Address - Fax:
Practice Address - Street 1:15027 CALLE LA PALOMA
Practice Address - Street 2:
Practice Address - City:CHINO HILLS
Practice Address - State:CA
Practice Address - Zip Code:91709-5011
Practice Address - Country:US
Practice Address - Phone:909-973-3178
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-10-23
Last Update Date:2020-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95014273363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA95014273OtherBOARD OF REGISTERED NURSING - NURSE PRACTITIONER LICENSE